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Abstract

Background: Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective
HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on
provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the providerinitiated
testing model, but there is limited documentation of experiences with this new service model. The aim of
this study was to determine the use of different types of HIV testing services and to investigate perceptions and
experiences of these services with a particular emphasis on the provider initiated testing in three selected districts
in Kenya, Tanzania, and, Zambia.
Methods: A concurrent triangulation mixed methods design was applied using quantitative and qualitative
approaches. A population-based survey was conducted among adults in the three study districts, and qualitative
data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the
ongoing EU funded research project “REsponse to ACountable Priority Setting for Trust in Health Systems” (REACT)
implemented in the three countries which has a research component linked to HIV and testing, and from an
additional study focusing on HIV testing, counselling perceptions and experiences in Kenya.
Results: Proportions of the population formerly tested for HIV differed sharply between the study districts and
particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much
more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child
transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In
places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was
accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures.
Informants expressed frustration related to their experienced inability to ‘opt-out’ or decline from the providerinitiated
HIV testing services.
Conclusion: Counselling emerged as a highly valued process during HIV testing. However, counselling efforts were
limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not
perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in
the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to
pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to
their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the
manner in which the provider initiated HIV testing model is implemented in order to protect the client’s autonomy
and to maximise access to HIV prevention.